Information Collection

Clinic Questionaires

IC 182191 under ICR 200901-0925-003 · OMB 0925-0584.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0584 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9 Clinic Questionaires	Form and Instruction
1 Alcohol Use Alcohol Use_06-07-07.doc	Form and Instruction
2 Dietary Recall and Supplement Use Diet and Supplement Phone Script recall.doc	Form and Instruction
3 Dietary Behavior Dietary Beh_6-25-07.doc	Form and Instruction
4 Economic Economic_7-04-07.doc	Form and Instruction
5 Health Care Use Health Care Use_7-06-07.doc	Form and Instruction
6 Hearing Exam Hearing Exam Qx_07-04-07.doc	Form and Instruction
7 Informed Consent Informed consent.doc	Form and Instruction
8 Medical History Medical History_6-28-07.doc	Form and Instruction
9 Medication Use Medication Survey_07-02-07.doc	Form and Instruction
10 Neuro Neurocognitive Assessment_07-31-07.doc	Form and Instruction
11 Occupation Occupation_7-04-07.doc	Form and Instruction
12 Oral Health Oral Health_07-09-07.doc	Form and Instruction
14 Physical Activity Physical Activity_7-24-07.doc	Form and Instruction
15 Respiratory Respiratory_7-05-07.doc	Form and Instruction
16 SF 12 SF12v2 Health Survey_4-30-07.doc	Form and Instruction
17 Sleep Sleep_6-29-07.doc	Form and Instruction
18 Social Cultural Sociocultural_07-04-07.doc	Form and Instruction
19 Tobacco Use Tobacco Use_6-18-07.doc	Form and Instruction
20 Weight History Weight History_7-03-07.doc	Form and Instruction
21 Well Being Wellbeing_5-25-07.doc	Form and Instruction
22 survey Claudication_2-25-08.doc	Form and Instruction
23 survey Personal Information_11-21-08.doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Clinic Questionaires

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	9	Medication Use	Medication Survey_07-02-07.doc	Yes	Yes	Paper Only
Form and Instruction	15	Respiratory	Respiratory_7-05-07.doc	Yes	Yes	Paper Only
Form and Instruction	16	SF 12	SF12v2 Health Survey_4-30-07.doc	Yes	Yes	Paper Only
Form and Instruction	17	Sleep	Sleep_6-29-07.doc	Yes	Yes	Paper Only
Form and Instruction	18	Social Cultural	Sociocultural_07-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	19	Tobacco Use	Tobacco Use_6-18-07.doc	Yes	Yes	Paper Only
Form and Instruction	20	Weight History	Weight History_7-03-07.doc	Yes	Yes	Paper Only
Form and Instruction	21	Well Being	Wellbeing_5-25-07.doc	Yes	Yes	Paper Only
Form and Instruction	22	survey	Claudication_2-25-08.doc	Yes	Yes	Paper Only
Form and Instruction	23	survey	Personal Information_11-21-08.doc	Yes	Yes	Paper Only
Form and Instruction	14	Physical Activity	Physical Activity_7-24-07.doc	Yes	Yes	Paper Only
Form and Instruction	1	Alcohol Use	Alcohol Use_06-07-07.doc	Yes	Yes	Paper Only
Form and Instruction	2	Dietary Recall and Supplement Use	Diet and Supplement Phone Script recall.doc	Yes	Yes	Paper Only
Form and Instruction	3	Dietary Behavior	Dietary Beh_6-25-07.doc	Yes	Yes	Paper Only
Form and Instruction	4	Economic	Economic_7-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	5	Health Care Use	Health Care Use_7-06-07.doc	Yes	Yes	Paper Only
Form and Instruction	6	Hearing Exam	Hearing Exam Qx_07-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	7	Informed Consent	Informed consent.doc	Yes	Yes	Paper Only
Form and Instruction	8	Medical History	Medical History_6-28-07.doc	Yes	Yes	Paper Only
Form and Instruction	10	Neuro	Neurocognitive Assessment_07-31-07.doc	Yes	Yes	Paper Only
Form and Instruction	11	Occupation	Occupation_7-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	12	Oral Health	Oral Health_07-09-07.doc	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,333	0	5,333
Annual IC Time Burden (Hours)	15,039	373	14,666
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.